Post-Acute Care Episodes Expanded Analytic File. 6. Geographic Benchmarking

04/01/2011

After exploring episode utilization and payments by type of initiating event and by episode definition, and looking at the relationship between episode utilization and mortality, ASPE and RTI also stratified the episode descriptives by geographic area to illustrate the differences across the country due to PAC provider supply and differences in practice patterns. In these analyses, we stratified episode descriptives by state and by core-based statistical area (CBSA) based on the location of the index provider. In many cases the location of the index provider and beneficiary residence are the same, but some beneficiaries cross state lines and metropolitan areas to receive care. Analyses conducted in 2009 generated the geographic descriptive based both on the location of the index provider and on the location of the beneficiary and found little difference in the mean PAC payment per PAC user or per discharge (Morley et al. 2009; Gage et al., 2009). For this reason, we provide the episode descriptives in this report based only on the location of the index provider. Provider state and county were identified using the Provider of Service (POS) file, and CBSA was assigned using a county-to-CBSA crosswalk available from CMS. Standardized payment amounts were used here to remove the effects of wages and other adjustments that vary by geography. These analyses were performed on the 30-day fixed-episode definition, including any claim initiating within 30 days after discharge from the initiating event.

Table 47 contains the results of the first geographic analysis. This table reports the number and percentage of beneficiaries with acute hospital-initiated episodes discharged to PAC in different states, along with the mean payment per hospital discharge, the mean payment per PAC user, and the mean PAC length of stay for 2008. In terms of mean PAC payment per PAC user, the states included in this table are the top 5, the middle 10, and the bottom 5. These states were selected to demonstrate the range in payments per PAC user across the country. At over $14,000, Louisiana and Texas have the highest mean payments per PAC user. In Louisiana, 35.2 percent of beneficiaries are discharged to PAC, and 38.8 percent are similarly discharged in Texas.2 Although these percentages are not higher than the national average of 38.7 percent, the mean PAC payments per PAC user are the highest nationally. In contrast, the lowest mean PAC payments per PAC user were in Oregon, South Dakota, Montana, Iowa, and Alaska. Each of these states also had lower-than-average percentages of discharge to PAC. Patterns of PAC episode length of stay were consistent with payments per PAC user with longer episodes in Texas and Louisiana and shorter episodes in Iowa and Alaska.

Table 47. Standardized Post-Acute Care Payments for Acute Hospital-Initiated Episodes, by State, 2008, Episode Definition 30-Day Fixed: Any Claim Starting Within 30 Days
State Number
of PAC
Users1
Percent of
Beneficiaries
Discharged
to PAC
2(%)
Mean PAC
Payment
Per Discharge3
($)
CV4 Mean PAC
Payment
Per PAC
User5
($)
CV4 Mean
PAC LOS
Per PAC
User6
(days)
CV4
  1. PAC users are defined as beneficiaries discharged to SNF, IRF, LTCH, HHA, or therapy following discharge from an index acute hospitalization.
  2. Percentage of beneficiaries discharged to PAC is calculated as the proportion of PAC user of beneficiaries with 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.
  3. Post-Acute care includes Medicare payments for SNF, IRF, LTCH, HHA, therapy and acute hospital readmission. 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.
  4. Coefficient of variation (CV) is the ratio of the standard deviation to the mean.
  5. Post-Acute care includes Medicare payments for SNF, IRF, LTCH, HHA, therapy, and acute hospital readmission. Per-PAC user calculations include only beneficiaries discharged to PAC.
  6. 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.

Source: RTI analysis of 2008 Medicare claims (M3MM200).

Top 5 States for Mean PAC Payment Per PAC User
LA   9,160 35.2 $6,291 2.2 $14,864 1.3 48.7 0.6
TX 41,438 38.3 $6,453 2.0 $14,387 1.2 47.2 0.6
NV   3,853 37.3 $6,355 2.1 $14,359 1.2 39.6 0.6
IN 17,038 37.9 $6,362 2.0 $14,282 1.2 42.2 0.7
OH 29,900 40.2 $6,161 2.0 $12,982 1.2 40.5 0.7
Middle 10 States for Mean PAC Payment Per PAC User
CO   7,266 39.7 $5,418 2.1 $11,571 1.3 37.4 0.7
FL 49,482 43.0 $5,772 1.9 $11,536 1.2 39.9 0.6
NM   2,683 32.1 $4,528 2.2 $11,463 1.2 42.2 0.6
AL 11,617 31.2 $4,442 2.3 $11,457 1.2 45.0 0.6
GA 15,553 32.3 $4,645 2.3 $11,430 1.3 42.2 0.7
MO 16,991 37.2 $5,220 2.1 $11,429 1.3 39.6 0.8
MI 25,376 39.3 $5,306 2.1 $11,293 1.3 41.0 0.7
DE   2,757 42.7 $5,614 1.9 $11,189 1.2 36.7 0.6
NH   3,796 47.3 $4,528 2.2 $11,161 1.3 42.3 0.7
AZ   8,563 30.6 $4,376 2.3 $11,097 1.2 33.8 0.6
Bottom 5 States for Mean PAC Payment Per PAC User
OR   4,578 33.2 $3,838 2.1   $8,925 1.2 35.7 0.6
SD   2,294 35.3 $3,853 2.4   $8,747 1.5 34.0 0.9
MT   2,215 31.9 $3,525 2.4   $8,429 1.4 35.5 0.8
IA   8,498 36.2 $3,787 2.2   $8,092 1.3 32.8 0.8
AK      491 21.7 $2,626 3.1   $7,395 1.8 33.8 0.7

By displaying the mean PAC payment per PAC user and the mean PAC payment per discharge, we can see the effect of using different denominators over which to calculate mean payments at the state level. Comparing both calculations highlights the impact of the percentage of beneficiaries discharged to PAC as well as the use per PAC user. In Figure 4 these differences are shown graphically for 10 states. The states shown here represent two from the top 5 in terms of mean PAC payment per PAC user (Texas and Ohio), three from the middle 10 (Florida, Michigan, and New Hampshire), and 2 from the bottom five (Oregon and Montana). In addition to these 7, we also chose to include Massachusetts, California, and New York in this figure because of their population size and the differences in supply and practice patterns that they represent. The figure displays both the mean payment per PAC user and the mean payment per discharge in these 10 states. By presenting both of these numbers in the same graph, we can see that though Texas has the highest mean PAC payment per PAC user of the states shown here, and Massachusetts has a higher mean payment per discharge due to the higher proportion of beneficiaries in Massachusetts discharged to PAC (50.5%). The dotted lines across the figure represent the mean payment per PAC user based on the mean and median nationally. The national mean and median are shown here to provide benchmarks for comparing state payments to national payments. Six of the 10 states shown here have mean payments per PAC user lower than the national average, and four states have higher mean payments per PAC user than the national average. Differences in provider supply and practice patterns are clearly an important consideration in developing an episode-based payment.

Figure 4. Benchmarking Analysis: Mean PAC Episode Payment Per PAC User, and Per Discharge for Acute Initiated Episodes, By State, Episode Definition 30-day Fixed Any Claim Starting Within 30 Days, 2008

Figure 4.    

Figure 4 is a bar chart reporting the mean PAC payment per discharge and the mean PAC payment per PAC User by state for beneficiaries under the episode definition 30-Day Fixed: Any Claim Starting within 30 Days in 2008. Data for Texas, Ohio, Massachusetts, California, Florida, Michigan, New Hampshire, New York, Oregon, and Montana are shown here. The mean and median national payment per PAC user are also reported to allow for an understanding of how the states compare to each other and how they compare to the nation overall.

Source: RTI analysis of 2006, 2007, and 2008 Medicare claims (M3MM200).

Although the state-level PAC episode analysis reveals important differences across geographic areas, the CBSA-level analysis highlights additional variation within states and across metropolitan areas. Table 48 contains PAC episode descriptives for acute hospital-initiated episodes for the top 20 CBSAs in terms of the number of PAC users. Although New York, Illinois, California, Philadelphia, and Massachusetts were not among the top states in mean PAC payment per PAC user, metropolitan areas within these states are at the top in terms of the numbers of beneficiaries using PAC services. Three CBSAs in Texas are among the top 20 nationally, including Houston, Dallas, and rural Texas. In looking at these three CBSA areas alone, we see differences in use patterns within Texas. Although 38.3 percent of beneficiaries are discharged to PAC in Texas overall, 37.0 percent were discharged to PAC in Houston, 38.1 percent in rural Texas, and 41.0 percent in Dallas. There is significant variation in mean PAC payment per PAC user among the CBSAs shown here, with Houston having the highest (and fifth highest across all CBSAs) at $16,188 and Baltimore having the lowest at $10,124.

Table 48. Standardized Post-Acute Care Payments for Acute Hospital-Initiated Episodes, by CBSA, 2008, Episode Definition of 30-Day Fixed: Any Claim Starting Within 30 Days
Top 20 CBSAs
by Volume of PAC Users
Number
of PAC
Users1
Percent of Beneficiaries Discharged
to PAC2
(%)
Mean PAC Payment
Per Discharge3
($)
CV4 Mean PAC Payment
Per PAC User5
($)
CV4 Mean
PAC LOS Per PAC User6 (days)
CV4
  1. PAC users are defined as beneficiaries discharged to SNF, IRF, LTCH, HHA, or therapy following discharge from an index acute hospitalization.
  2. Percentage of beneficiaries discharged to PAC is calculated as the proportion of PAC user of beneficiaries with 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.
  3. Post-Acute care includes Medicare payments for SNF, IRF, LTCH, HHA, therapy, and acute hospital readmission. 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.
  4. Coefficient of variation (CV) is the ratio of the standard deviation to the mean.
  5. Post-Acute care includes Medicare payments for SNF, IRF, LTCH, HHA, therapy, and acute hospital readmission. Per-PAC user calculations include only beneficiaries discharged to PAC.
  6. 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.

Source: RTI analysis of 2008 Medicare claims (M3MM200).

New York-White Plains-Wayne, NY-NJ 23,031 43.1 $5,998 1.7 $11,687 1.1 39.7 0.6
Chicago-Naperville-Joliet, IL 19,111 41.3 $6,105 1.9 $12,354 1.1 41.9 0.6
Los Angeles-Long Beach-Santa Ana, CA 13,403 42.8 $6,682 1.9 $13,320 1.2 43.5 0.6
Philadelphia, PA   9,986 45.6 $5,709 1.9 $10,755 1.2 38.2 0.7
Nassau-Suffolk, NY   9,023 43.2 $5,459 1.7 $10,757 1.0 37.8 0.6
Boston-Quincy, MA   8,151 49.7 $6,735 1.8 $11,881 1.2 43.5 0.6
St. Louis, MO-IL   7,953 39.3 $5,373 2.1 $11,174 1.3 39.5 0.7
Tampa-St. Petersburg-Clearwater, FL   7,546 44.4 $6,119 1.9 $11,995 1.2 39.7 0.6
Houston-Sugar Land-Baytown, TX   7,544 37.0 $7,072 2.1 $16,188 1.2 45.6 0.6
Edison, NJ   7,213 47.4 $6,676 1.7 $12,396 1.0 38.1 0.6
Cleveland-Elyria-Mentor, OH   6,817 41.7 $6,417 1.8 $13,096 1.1 40.5 0.6
Warren-Troy-Farmington-Hills, MI   6,777 40.8 $5,591 2.0 $11,543 1.2 41.7 0.6
Baltimore-Towson, MD   6,652 33.0 $4,377 2.0 $10,124 1.1 34.2 0.6
Atlanta-Sandy Springs-Marietta, GA   6,343 33.6 $4,943 2.3 $11,818 1.3 43.9 0.6
Washington-Arlington-Alexandria DC-VA   6,279 37.6 $4,979 2.0 $10,794 1.2 36.7 0.7
Rural NC   6,003 33.5 $4,641 2.1 $11,083 1.2 41.6 0.7
Newark-Union, NJ-PA   5,836 44.0 $6,518 1.8 $12,904 1.0 39.8 0.6
Dallas-Plano-Irving, TX   5,779 41.0 $6,927 1.9 $14,685 1.1 46.6 0.6
Pittsburgh, PA   5,360 47.0 $6,696 1.9 $12,362 1.2 39.2 0.6
Rural TX   5,128 38.1 $5,743 2.1 $12,789 1.2 48.3 0.6

In addition to the geographic analysis for acute hospital-initiated episodes, we also performed geographic analysis for HHA-initiated episodes. Because of the small numbers of beneficiaries with LTCH- and IRF-initiated episodes at the state and CBSA levels, geographic analyses for these types of episodes are not presented here. Table 49 shows the mean PAC payment per user for the top 5 states, the middle 10 states, and the bottom 5 states. The states with the highest payments per HHA-initiated episode are Indiana and Tennessee, and the states with the lowest payments are Vermont and Oregon. Although there is variation in the PAC episode payment across states, there is also significant variation in the number of beneficiaries with HHA-initiated episodes in each of the states shown in Table 49 with Texas, California, and Michigan among the top. To reveal more about the geographic areas with the highest volume of these types of cases, Table 50 presents the top 20 CBSAs in terms of the number of HHA-initiated episodes. Although Chicago and Los Angeles have the highest volume of HHA community-initiated episodes, these types of episodes are also common to several different metropolitan areas in Texas and Florida as well as rural areas of Texas, Mississippi, Oklahoma, and North Carolina.

Table 49. Standardized Post-Acute Care Payments for HHA-Initiated Episodes, by State, 2008, Episode Definition of 30-Day Fixed: Any Claim Starting Within 30 Days
State N Mean Episode Payment1
($)
CV2 Mean Episode LOS1
(days)
CV2
  1. 1. 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.
  2. 2. Coefficient of variation (CV) is the ratio of the standard deviation to the mean.

Source: RTI analysis of 2008 Medicare claims (M3MM200).

Top 5 States for Mean Episode Payment Per User
IN   3,904 $7,732 1.6 66.3 0.6
TN   6,354 $7,656 1.4 76.1 0.5
WV      962 $7,376 1.5 65.2 0.6
CT   3,441 $7,333 1.4 56.9 0.7
WY      186 $7,320 1.5 60.7 0.6
Middle 10 States for Mean Episode Payment Per User
GA   6,706 $6,565 1.5 66.4 0.6
NV   1,779 $6,519 1.6 62.0 0.6
NC   6,650 $6,479 1.5 57.4 0.7
NE      840 $6,461 1.4 53.8 0.7
TX 23,528 $6,451 1.3 86.6 0.4
DE      449 $6,441 1.3 52.0 0.7
MO   4,311 $6,413 1.5 55.5 0.7
VA   5,366 $6,412 1.4 57.8 0.7
WI   1,840 $6,403 1.3 52.6 0.7
MI 14,321 $6,385 1.4 64.7 0.6
Bottom 5 States for Mean Episode Payment Per User
CA 19,251 $5,690 1.4 55.1 0.7
SD      236 $5,621 1.4 42.5 0.8
MT      400 $5,603 1.2 48.8 0.7
VT      739 $5,580 1.3 59.2 0.7
OR   1,733 $5,239 1.3 49.7 0.7
Table 50. Standardized Post-Acute Care Payments for HHA-Initiated Episodes, by CBSA, 2008, Episode Definition of 30-Day Fixed: Any Claim Starting Within 30 Days
CBSA Number
of
PAC
Users
Mean
PAC
Payment
Per PAC
User
($)
CV Mean PAC
LOS
Per PAC
User (days)
CV
Source: RTI Analysis of 2008 Medicare Claims (M3MM200).
Chicago-Naperville-Joliet, IL 11,599 $6,000 1.8 83.7 0.4
Los Angeles-Long Beach-Santa Ana, CA   9,124 $5,562 1.7 62.9 0.5
Warren-Troy-Farmington-Hills, MI   7,303 $6,158 1.5 67.6 0.5
New York-White Plains-Wayne, NY-NJ   6,447 $6,042 1.6 51.3 0.6
Miami-Miami Beach-Kendall, FL   5,261 $4,836 1.6 57.7 0.5
Tampa-St. Petersburg-Clearwater, FL   5,005 $6,081 1.6 53.3 0.6
West Palm Beach-Boca Raton-Boynton FL   4,311 $5,752 1.6 53.2 0.6
Houston-Sugar Land-Baytown, TX   4,297 $6,410 1.6 87.9 0.4
Dallas-Plano-Irving, TX   3,885 $6,376 1.8 88.3 0.3
Ft Lauderdale-Pompano Beach-Deerfield   3,136 $5,548 1.7 56.5 0.6
Rural TX   3,098 $6,316 1.5 88.8 0.4
Atlanta-Sandy Springs-Marietta, GA   2,956 $6,518 1.7 68.0 0.5
Philadelphia, PA   2,632 $6,261 1.6 57.8 0.6
McAllen-Edinburg-Mission, TX   2,549 $5,475 1.5 92.1 0.3
Rural MS   2,415 $7,398 1.8 86.9 0.4
Detroit-Livonia-Dearborn, MI   2,408 $6,587 1.7 67.6 0.6
St. Louis, MO-IL   2,274 $6,421 1.5 57.2 0.6
Jacksonville, FL   2,019 $6,182 1.6 62.7 0.5
Rural OK   1,926 $7,134 1.7 89.2 0.4
Rural NC   1,893 $6,858 1.6 61.9 0.6

 

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