Post-Acute Care Episodes Expanded Analytic File. 5. Mortality Analyses

04/01/2011

In addition to the episode descriptives presented in Sections 3 and 4, RTI stratified analyses by type of initiated event (acute, HHA, LTCH, and IRF) and by whether beneficiaries died during the episode. This mortality analysis was conducted for two episode definitions: the 30-day variable-length episode definition and the 30-day fixed-length with any claim initiating within 30 days after discharge from the index event. These episode definitions were chosen because they allow us to look at timing of death and differences in service utilization under a shorter versus longer episode definition. Note that these mortality analyses were conducted to learn more about trajectories of care and service use, and were not intended for quality measurement.

In looking at acute hospital-initiated episodes, 7.7 percent of beneficiaries die in their episode under the 30-day variable-length episode definition (Table 39). This percentage decreases to 4.4 percent when looking at the shorter 30-day fixed episode definition with any claim initiating within 30 days of discharge from the index acute hospitalization (Table 40). These tables also indicate that beneficiaries who die in their episodes have higher index acute hospitalization length and payment suggesting that these beneficiaries are likely more complex when they initiate care. However, mean episode length does not differ substantially between beneficiaries dying during the episode under the 30-day variable-length episode definition (87.5 days for those who are alive at the end of the episode and 84.6 days for those who die before the end of the episode). Compared with beneficiaries who survive until the end of the episode, a higher proportion of beneficiaries who die before the end of the episode use SNF (76.0 percent versus 45.8 percent), LTCH (10.6 percent versus 1.9 percent), and have an acute hospitalization (68.6 percent versus 25.0 percent). In contrast, a higher proportion of beneficiaries surviving to the end of the episode used IRF, HHA, and therapy services. Similar results were revealed in looking at service use under the shorter 30-day fixed episode definition with any claim initiating within 30 days of discharge from the index acute hospitalization.

Table 39. Mortality Analyses, Acute Hospital-Initiated Episodes, 30-Day Variable-Length Episode Definition, 2008
30-Day Variable-Length Episode Definition Beneficiaries Alive
at End of Episode
Beneficiaries Dying
During Episode
  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.
  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 the index acute hospitalization, SNF, IRF, LTCH, HHA, therapy, and acute hospital readmissions.
  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. PAC payments include Medicare payments for SNF, IRF, LTCH, HHA, therapy, and acute hospital readmissions.
  4. "Per service user" indicates mean Medicare payments for those beneficiaries who use the service.

Source: RTI analysis of 2008 Medicare claims (M3MM155).

Number of Beneficiaries 608,499 51,050
Percent of Beneficiaries 92.3 7.7
Mean Index Acute Hospital Length of Stay1 5.9 9.0
Mean Index Acute Hospital Payment1 $10,392 $12,712
Mean Episode Length of Stay (days)2 87.5 84.6
Mean Episode Payments2 $26,281 $46,018
Mean PAC Length of Stay (days)3 79.4 74.5
Mean PAC Payments3 $15,888 $33,306
HHA
Percent with Claim 62.8 34.6
Mean Visits Per Service User4 25.3 31.2
Mean Payment Per Service User4 $4,213 $4,599
IRF
Percent with Claim 9.9 7.3
Mean Length of Stay Per Service User (days)4 14.3 15.6
Mean Payment Per Service User4 $17,444 $18,718
LTCH
Percent with Claim 1.9 10.6
Mean Length of Stay Per Service User (days) 4 32.1 30.3
Mean Payment Per Service User4 $38,092 $40,756
SNF
Percent with Claim 45.8 76.0
Mean Length of Stay Per Service User (days) 4 40.2 33.4
Mean Payment Per Service User4 $13,920 $11,676
Outpatient Therapy
Percent with Claim 21.2 9.6
Mean Payment Per Service User4 $1,410 $1,409
Independent Therapist
Percent with Claim 10.3 1.0
Mean Payment Per Service User4 $1,210 $1,083
Acute Hospital Readmission
Percent with Claim 25.0 68.6
Mean Length of Stay Per Service User (days) 4 10.5 14.9
Mean Payment Per Service User4 $15,891 $24,807
Table 40. Mortality Analyses, Acute Hospital-Initiated Episodes, 30-Day Fixed-Length Episode Definition, 2008
30-Day Fixed-Length Episode Definition Beneficiaries Alive
at End of Episode
Beneficiaries Dying
During Episode
  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.
  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 the index acute hospitalization, SNF, IRF, LTCH, HHA, therapy, and acute hospital readmissions.
  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. PAC payments include Medicare payments for SNF, IRF, LTCH, HHA, therapy, and acute hospital readmissions.
  4. "Per service user" indicates mean Medicare payments for those beneficiaries who use the service.

Source: RTI analysis of 2008 Medicare claims (M3MM155).

Number of Beneficiaries 630,573 28,976
Percent of Beneficiaries 95.6 4.4
Mean Index Acute Hospital Length of Stay (days)1 6.0 9.3
Mean Index Acute Hospital Payment1 $10,466 $12,889
Mean Episode Length of Stay (days)2 49.2 39.0
Mean Episode Payments2 $20,885 $28,581
Mean PAC Length of Stay (days)3 41.1 29.0
Mean PAC Payments3 $10,420 $15,693
HHA
Percent with Claim 53.7 21.0
Mean Visits Per Service User4 15.9 8.8
Mean Payment Per Service User4 $2,806 $1,720
IRF
Percent with Claim 9.2 4.5
Mean Length of Stay Per Service User (days)4 13.5 10.5
Mean Payment Per Service User4 $16,585 $12,867
LTCH
Percent with Claim 1.7 8.2
Mean Length of Stay Per Service User (days) 4 28.7 21.6
Mean Payment Per Service User4 $36,040 $31,503
SNF
Percent with Claim 44.0 73.8
Mean Length of Stay Per Service User (days) 4 33.3 18.9
Mean Payment Per Service User4 $11,830 $6,879
Outpatient Therapy
Percent with Claim 12.0 2.5
Mean Payment Per Service User4 $630 $376
Independent Therapist
Percent with Claim 6.6 0.2
Mean Payment Per Service User4 $358 $289
Acute Hospital Readmission
Percent with Claim 13.4 45.1
Mean Length of Stay Per Service User (days) 4 7.3 8.1
Mean Payment Per Service User4 $10,963 $15,680

In the mortality analysis of beneficiaries initiating episodes in HHA, 4.5 percent died under the longer 30-day variable-length episode definition (Table 41) and 2.5 percent died under the shorter 30-day fixed episode definition (Table 42). Under the 30-day variable-length episode definition, beneficiaries dying during the episode have a higher number of HHA visits in the index event than those who survive, but under the shorter 30-day fixed definition, beneficiaries who die have fewer visits during their index HHA claim. A higher proportion of beneficiaries dying during an HHA-initiated episode used IRF, LTCH, SNF, and had an acute hospitalization. Under the 30-day variable definition, 82.5 percent of beneficiaries dying during the episode have an acute hospitalization during their episode compared with 20.3 percent of beneficiaries who survive until the end of the episode. Results were similar across the two episode definitions examined.

Table 41. Mortality Analyses, HHA-Initiated Episodes, 30-Day Variable-Length Episode Definition, 2008
30-Day Variable-Length Episode Definition Beneficiaries Alive
at End of Episode
Beneficiaries Dying
During Episode
  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. 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, therapy, and acute hospitalizations.
  3. Service use for the initiating event is not included in this calculation.
  4. Per service user" indicates mean Medicare payments for those beneficiaries who use the service.

Source: RTI analysis of 2008 Medicare claims (M3MM155).

Number of Beneficiaries 225,632 10,675
Percent of Beneficiaries 95.5 4.5
Mean Index HHA Visits1 16.8 17.3
Mean Index HHA Payment1 $2,791 $2,529
Mean Episode Length of Stay (days)2 112.0 135.6
Mean Episode Payments2 $10,685 $33,951
HHA (not including initiating event)3
Percent with Claim 34.9 45.9
Mean Visits Per Service User4 64.4 58.1
Mean Payment Per Service User4 $8,530 $7,423
IRF
Percent with Claim 1.4 3.7
Mean Length of Stay Per Service User (days) 4 16.3 15.2
Mean Payment Per Service User4 $19,359 $18,261
LTCH
Percent with Claim 0.6 6.3
Mean Length of Stay Per Service User (days) 4 34.5 30.0
Mean Payment Per Service User4 $38,546 $38,467
SNF
Percent with Claim 8.0 37.1
Mean Length of Stay Per Service User (days) 4 50.6 35.3
Mean Payment Per Service User4 $17,373 $12,614
Outpatient Therapy
Percent with Claim 7.3 8.6
Mean Payment Per Service User4 $1,388 $1,192
Independent Therapist
Percent with Claim 3.5 1.5
Mean Payment Per Service User4 $1,240 $959
Acute Hospitalization
Percent with Claim 20.3 82.5
Mean Length of Stay Per Service User (days) 4 9.8 15.3
Mean Payment Per Service User4 $14,204 $24,397
Table 42. Mortality Analyses, HHA-Initiated Episodes, 30-Day Fixed-Length Episode Definition, 2008
30-Day Fixed-Length Episode Definition1 Beneficiaries Alive at End of Episode Beneficiaries Dying During Episode
  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. 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, therapy, and acute hospitalizations.
  3. Service use for the initiating event is not included in this calculation.
  4. Per service user" indicates mean Medicare payments for those beneficiaries who use the service.

Source: RTI analysis of 2008 Medicare claims (M3MM155).

Number of Beneficiaries 230,357 5,950
Percent of Beneficiaries 97.5 2.5
Mean Index HHA Visits1 16.9 12.8
Mean Index HHA Payment1 $2,796 $2,144
Mean Episode Length of Stay (days)2 64.4 50.3
Mean Episode Payments2 $6,173 $17,008
HHA (not including initiating event)3
Percent with Claim 33.5 16.2
Mean Visits Per Service User4 18.6 9.5
Mean Payment Per Service User4 $2,723 $1,709
IRF
Percent with Claim 0.8 1.4
Mean Length of Stay Per Service User (days)4 15.0 12.0
Mean Payment Per Service User4 $17,875 $15,496
LTCH
Percent with Claim 0.2 2.5
Mean Length of Stay Per Service User (days)4 29.7 26.4
Mean Payment Per Service User4 $33,346 $32,695
SNF
Percent with Claim 5.1 24.2
Mean Length of Stay Per Service User (days)4 38.3 20.3
Mean Payment Per Service User4 $13,530 $7,368
Outpatient Therapy
Percent with Claim 4.6 3.8
Mean Payment Per Service User4 $661 $454
Independent Therapist
Percent with Claim 2.7 0.4
Mean Payment Per Service User4 $459 $390
Acute Hospitalization
Percent with Claim 15.2 73.8
Mean Length of Stay Per Service User (days)4 7.0 9.8
Mean Payment Per Service User4 $9,888 $15,951

Analysis of the LTCH-initiated episode revealed that 17.8 percent of LTCH community entrants die before the end of the episode under the 30-day variable-length definition (Table 43). This percentage decreases to 13.5 under the shorter 30-day fixed definition (Table 44). Mean index LTCH length of stay is similar across those who die and those who survive, but under the 30-day variable-length episode the total episode length of stay is much shorter for beneficiaries who die during the episode (68.2 days compared with 108.8 days). A higher proportion of beneficiaries who survive through the end of the episode use subsequent PAC and have acute hospitalization during the episode. Of those that survive until the end of the episode under the 30-day variable length definition, 26.8 percent of beneficiaries who survive have an acute hospitalization compared with 42.0 percent of those who die. Similar results were found in looking at the shorter episode definition; however, the proportion of beneficiaries using each service was lower.

Table 43. Mortality Analyses, LTCH-Initiated Episodes, 30-Day Variable-Length Episode, 2008
30-Day Variable-Length Episode Definition Beneficiaries Alive
at End of Episode
Beneficiaries Dying
During Episode
  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, therapy, and acute hospitalizations.
  3. Per service user" indicates mean Medicare payments for those beneficiaries who use the service.
  4. Service use for the initiating event is not included in this calculation.

Source: RTI analysis of 2008 Medicare claims (M3MM155).

Number of Beneficiaries 4,083 884
Percent of Beneficiaries 82.2 17.8
Mean Index LTCH Length of Stay (days)1 26.5 27.9
Mean Index LTCH Hospital Payment1 $24,850 $33,638
Mean Episode Length of Stay (days)2 108.8 68.2
Mean Episode Payments2 $44,387 $57,006
HHA
Percent with Claim 26.8 11.4
Mean Visits Per Service User3 59.9 50.2
Mean Payment Per Service User3 $8,088 $6,556
IRF
Percent with Claim 3.8 2.3
Mean Length of Stay Per Service User (days)3 18.5 21.2
Mean Payment Per Service User3 $21,436 $24,642
LTCH (not including initiating event)4
Percent with Claim 12.5 17.1
Mean Length of Stay Per Service User (days)3 41.4 38.1
Mean Payment Per Service User3 $37,122 $43,034
SNF
Percent with Claim 33.4 30.7
Mean Length of Stay Per Service User (days)3 60.1 36.5
Mean Payment Per Service User3 $17,544 $11,850
Outpatient Therapy
Percent with Claim 15.3 5.4
Mean Payment Per Service User3 $2,633 $2,200
Independent Therapist
Percent with Claim 1.6 0.2
Mean Payment Per Service User3 $1,400 $110
Acute Hospitalization
Percent with Claim 26.8 42.0
Mean Length of Stay Per Service User (days) 3 14.6 14.9
Mean Payment Per Service User3 $20,996 $26,110
Table 44. Mortality Analyses, LTCH-Initiated Episodes, 30-Day Fixed-Length Episode Definition, 2008
30-Day Fixed-Length Episode Definition Beneficiaries Alive
at End of Episode
Beneficiaries Dying
During Episode
  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, therapy, and acute hospitalizations.
  3. Per service user" indicates mean Medicare payments for those beneficiaries who use the service.
  4. Service use for the initiating event is not included in this calculation.

Source: RTI analysis of 2008 Medicare claims (M3MM155).

Number of Beneficiaries 4,295 672
Percent of Beneficiaries 86.5 13.5
Mean Index LTCH Length of Stay (days)1 26.6 27.5
Mean Index LTCH Hospital Payment1 $25,363 $33,130
Mean Episode Length of Stay (days)2 60.9 38.1
Mean Episode Payments2 $35,565 $41,728
HHA
Percent with Claim 21.0 4.2
Mean Visits Per Service User3 23.1 9.7
Mean Payment Per Service User3 $3,226 $1,974
IRF
Percent with Claim 2.9 0.7
Mean Length of Stay Per Service User (days)3 17.8 17.6
Mean Payment Per Service User3 $21,422 $18,300
LTCH (not including initiating event)4
Percent with Claim 6.9 5.7
Mean Length of Stay Per Service User (days)3 35.1 36.3
Mean Payment Per Service User3 $30,095 $36,978
SNF
Percent with Claim 31.1 17.7
Mean Length of Stay Per Service User (days)3 45.3 17.7
Mean Payment Per Service User3 $13,446 $6,289
Outpatient Therapy
Percent with Claim 6.8 0.7
Mean Payment Per Service User3 $1,150 $568
Independent Therapist
Percent with Claim 0.8 0.1
Mean Payment Per Service User3 $425 $114
Acute Hospitalization
Percent with Claim 17.5 25.6
Mean Length of Stay Per Service User (days)3 10.0 8.6
Mean Payment Per Service User3 $14,662 $20,203

A much smaller proportion of beneficiaries with IRF-initiated episodes die during their episode, likely because beneficiaries in IRFs must be willing to participate in 3 hours of therapy per day. In looking at the 30-day variable-length episode definition, 3.9 percent of beneficiaries die (Table 45) and this decreases to 2.0 percent when looking at the shorter episode definition (Table 46). A higher proportion of beneficiaries with IRF-initiated episodes who die during their episode have more than one IRF claim in their episode, use SNF or LTCH, or have an acute hospitalization compared with those who survive. A higher proportion of beneficiaries surviving until the end of their episode use HHA and therapy services, and these patterns are consistent across the longer and shorter episode definitions.

Table 45. Mortality Analyses, IRF-Initiated Episodes, 30-Day Variable-Length Episode Definition, 2008
30-Day Variable-Length Episode Definition Beneficiaries Alive
at End of Episode
Beneficiaries Dying
During Episode
  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. 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, therapy, and acute hospitalizations.
  3. Per service user" indicates mean Medicare payments for those beneficiaries who use the service.
  4. Service use for the initiating event is not included in this calculation.

Source: RTI analysis of 2008 Medicare claims (M3MM155).

Number of Beneficiaries 11,485 471
Percent of Beneficiaries 96.1 3.9
Mean Index IRF Length of Stay (days)1 13.0 12.5
Mean Index IRF Payment1 $13,833 $13,837
Mean Episode Length of Stay (days)2 92.0 98.2
Mean Episode Payments2 $26,538 $52,539
HHA
Percent with Claim 48.5 38.6
Mean Visits Per Service User3 38.0 45.9
Mean Payment Per Service User3 $6,072 $6,396
IRF (not including initiating event)4
Percent with Claim 7.4 18.3
Mean Length of Stay Per Service User (days)3 18.0 15.7
Mean Payment Per Service User3 $20,674 $19,188
LTCH
Percent with Claim 1.2 7.9
Mean Length of Stay Per Service User (days)3 34.6 27.0
Mean Payment Per Service User3 $36,222 $29,687
SNF
Percent with Claim 22.7 57.7
Mean Length of Stay Per Service User (days)3 54.3 39.5
Mean Payment Per Service User3 $18,161 $13,544
Outpatient Therapy
Percent with Claim 24.8 12.1
Mean Payment Per Service User3 $1,898 $1,411
Independent Therapist
Percent with Claim 23.3 2.1
Mean Payment Per Service User3 $1,369 $1,441
Acute Hospitalization
Percent with Claim 20.7 76.6
Mean Length of Stay Per Service User (days)3 10.6 17.6
Mean Payment Per Service User3 $15,043 $29,189
Table 46. Mortality Analyses, IRF-Initiated Episodes, 30-Day Fixed-Length Episode Definition, 2008
30-Day Fixed-Length Episode Definition1 Beneficiaries Alive
at End of Episode
Beneficiaries Dying
During Episode
  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. 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, therapy, and acute hospitalizations.
  3. Per service user" indicates mean Medicare payments for those beneficiaries who use the service.
  4. Service use for the initiating event is not included in this calculation.

Source: RTI analysis of 2008 Medicare claims (M3MM155).

Number of Beneficiaries 11,716 240
Percent of Beneficiaries 98.0 2.0
Mean Index IRF Length of Stay (days)1 13.0 11.9
Mean Index IRF Payment1 $13,843 $13,324
Mean Episode Length of Stay (days)2 48.1 36.0
Mean Episode Payments2 $20,747 $29,965
HHA
Percent with Claim 40.5 18.3
Mean Visits Per Service User3 21.9 17.8
Mean Payment Per Service User3 $3,718 $2,918
IRF (not including initiating event)4
Percent with Claim 4.3 8.8
Mean Length of Stay Per Service User (days) 3 15.9 10.1
Mean Payment Per Service User3 $17,741 $11,416
LTCH
Percent with Claim 0.6 2.9
Mean Length of Stay Per Service User (days) 3 28.9 13.6
Mean Payment Per Service User3 $28,630 $11,976
SNF
Percent with Claim 19.8 42.9
Mean Length of Stay Per Service User (days) 3 44.5 21.5
Mean Payment Per Service User3 $14,991 $7,749
Outpatient Therapy
Percent with Claim 15.9 2.5
Mean Payment Per Service User3 $772 $173
Independent Therapist
Percent with Claim 3.2 0.0
Mean Payment Per Service User3 $396  
Acute Hospitalization
Percent with Claim 12.8 59.2
Mean Length of Stay Per Service User (days) 3 7.7 8.6
Mean Payment Per Service User3 $10,555 $19,314

The mortality analyses conducted here provide important information on the proportion of beneficiaries who die under each type of initiated episode and the episode payment associated with these beneficiaries. Given the finding that episode payments are substantially higher for beneficiaries who die in an episode, these results demonstrate the important implications of mortality status on total episode utilization and payments.

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