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Post Acute Care Episodes

Post Acute Care Episodes

Final Report Prepared for Susan Bogasky Assistant Secretary for Planning and Evaluation (ASPE) U.S. Department of Health and Human Services Hubert H. Humphrey Building, Room 443F5 200 Independence Avenue, SW Washington, DC 20201 Prepared by
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Footnotes

Exploring Episode-Based Approaches for Medicare Performance Measurement, Accountability and Payment Final Report. Footnotes

1 Public Law 109-171, February 8, 2006 2 Public Law 110-275, July 15, 2008 3 Medicare severity diagnostic related groups 4 Prospective payment system 5 Relative value unit 6 Ambulatory payment classification 7 Electroconvulsive therapy 8 Healthcare common procedures coding system 9 Disproportionate share 10 Gr
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References

Exploring Episode-Based Approaches for Medicare Performance Measurement, Accountability and Payment Final Report. References

Abt Associates Inc. (1997). Medicare Cataract Surgery Alternate Payment Demonstration: Final Evaluation Report . Cambridge, M.A. American Geriatrics Society (AGS) (2007). "Improving the Quality of Transitional Care for Persons with Complex Care Needs: American Geriatrics Society Position Statement." Assited Living Consult March/April: 30-32.
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Appendix F. Defining Professional Costs and

Exploring Episode-Based Approaches for Medicare Performance Measurement, Accountability and Payment Final Report. Appendix F. Defining Professional Costs and Evaluation and Management (E&M) Visits

Defining Professional Claims for the Purposes of Attribution Under a narrow definition professional services are care directly rendered by a physician or related provider. This definition therefore excludes pharmacy, facility, and direct medical equipment.   Broader definitions might include these services.
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Appendix E. Settings Involved in Episodes, by

Exploring Episode-Based Approaches for Medicare Performance Measurement, Accountability and Payment Final Report. Appendix E. Settings Involved in Episodes, by Condition and Measures Reported to Medicare Reporting Programs

(as of 12/08/2008, includes measures for 2009 reporting) Figure E1. Settings Involved in Episodes: AMI (MEGS)
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Appendix D. Standardized Payment Methodology

Exploring Episode-Based Approaches for Medicare Performance Measurement, Accountability and Payment Final Report. Appendix D. Standardized Payment Methodology

Average payments were standardized for each setting based on 2005 payment rates and payment policy to exclude variation in resource use due to geographic factors (i.e., area wages, geographic differences in medical liability costs, and urban/rural status) and policy considerations (i.e., indirect medical education (IME), and disproportionate share
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Appendix C. Episodes Related to Conditions of

Exploring Episode-Based Approaches for Medicare Performance Measurement, Accountability and Payment Final Report. Appendix C. Episodes Related to Conditions of Focus

Condition ETGs (version 6.0) MEGs Acute myocardial infarction 386500: Ischemic heart disease 11: Acute myocardial infarction Bacterial pneumonia 437400: Bacterial lung infections 510: Pneumonia: bacterial Breast cancer (limited to women) 635600: Malignant neoplasm of breast 212: Neoplasm, malignant: breast, female
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References

Exploring Episode-Based Approaches for Medicare Performance Measurement, Accountability and Payment Final Report. References

MaCurdy, Thomas, Jason Kerwin, Jonathan Gibbs, Eugene Lin, Carolyn Cotterman, Margaret O'Brien-Strain and Nick Theobald. 2008. "Evaluating the Functionality of the Symmetry ETG and Medstat MEG Software in Forming Episodes of Care Using Medicare Data." Burlingame, CA: Acumen, LLC.
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Specifications for Creating Medstat Records

Exploring Episode-Based Approaches for Medicare Performance Measurement, Accountability and Payment Final Report. Specifications for Creating Medstat Records

Regardless of whether a Medicare claim comes from an institutional or non-institutional source, the MEG grouper accepts one input record per claim.
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Specifications for Creating Symmetry Records

Exploring Episode-Based Approaches for Medicare Performance Measurement, Accountability and Payment Final Report. Specifications for Creating Symmetry Records

To create episodes of care, Symmetry inputs service-level records with each input record containing information on a single service item and up to four diagnoses per record. These records also include data on dates of service. Services are always identified on an institutional claim (IP, OP, SNF, HH and HS claims) by a revenue center code, and if
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Constructing Episodes of Care Using Symmetry and

Exploring Episode-Based Approaches for Medicare Performance Measurement, Accountability and Payment Final Report. Constructing Episodes of Care Using Symmetry and Medstat Groupers

The episode groupers utilize the primary diagnosis on claim line items to create and place the line items into episode. Only certain types of claims, as determined by procedure and revenue codes, can start an episode such as evaluation and management procedure codes, surgery procedure codes or specific inpatient facility revenue code.
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Appendix B. Specifications Used to Create

Exploring Episode-Based Approaches for Medicare Performance Measurement, Accountability and Payment Final Report. Appendix B. Specifications Used to Create Episodes[36]

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Appendix A. Diagnosis and Procedure Codes to

Exploring Episode-Based Approaches for Medicare Performance Measurement, Accountability and Payment Final Report. Appendix A. Diagnosis and Procedure Codes to Identify Conditions of Focus

Condition ICD-9 diagnosis codes How selected Source for dx codes Acute myocardial infarction 410.xx (only first for second Dx on the claim At least 1 inpatient claim with DX code during 1 year period CMS Chronic Care Warehouse Bacterial pneumonia 481.xx-483.xx (any Dx on claim)
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Next Steps: Future Research and Demonstration Work

Exploring Episode-Based Approaches for Medicare Performance Measurement, Accountability and Payment Final Report. Next Steps: Future Research and Demonstration Work

There is an absence of solid empirical work related to and few real-world applications of episode-based approaches that provide guidance on how best to construct and apply episodes of care in the context of performance measurement and/or payment policy.  The work done within this project was exploratory in nature and represents only a first step
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Potential Applications of Episodes of Care Along

Exploring Episode-Based Approaches for Medicare Performance Measurement, Accountability and Payment Final Report. Potential Applications of Episodes of Care Along a Continuum of Policy Reform Options

Using a building block approach, one could build an episode by starting narrowly to reflect the services delivered by one provider in a single setting for a specific illness or injury, then expand more broadly to reflect the services delivered in a single setting by multiple providers (such as the physician and the hospital during an inpatient sta
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7. A significant proportion of episodes involved

Exploring Episode-Based Approaches for Medicare Performance Measurement, Accountability and Payment Final Report. 7. A significant proportion of episodes involved care in multiple states.

A large proportion of episodes involved care delivered in multiple states, suggesting potential challenges for care coordination and creating accountable groups of providers for an episode when they are not geographically proximate.  Out-of-state care, particularly when not geographically promixate, could likely make it more difficult to coordin
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6. Differences exist between geographic areas in

Exploring Episode-Based Approaches for Medicare Performance Measurement, Accountability and Payment Final Report. 6. Differences exist between geographic areas in per episode payments and care patterns for similar episodes of care.

The mean number of total episodes of all types per beneficiary varied widely among the three states in our analysis, averaging 6.1 episodes per beneficiary in Oregon, 6.9 in Texas, and 8.0 in Florida.  In our analyses, average 2005 per-capita payments were highest in Florida and Texas ($8,380 and $8,432, respectively) and lowest in Oregon ($5,87
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5. Different methods for assigning

Exploring Episode-Based Approaches for Medicare Performance Measurement, Accountability and Payment Final Report. 5. Different methods for assigning responsibility for an episode to one or more providers yield different results.

The published literature finds that different methods for attributing episodes of care to providers have yielded different results, in terms of which physicians are assigned responsibility and what proportion of episodes can be assigned.  Our analyses of Medicare data produced similar results in terms of variability.  However, it is notable th
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4. During a single episode of care, the care

Exploring Episode-Based Approaches for Medicare Performance Measurement, Accountability and Payment Final Report. 4. During a single episode of care, the care provided was often dispersed among a large number of specialists, but typically involved a single primary care physician.

For most of the nine study conditions examined, the condition-related episodes involved a median of one PCP (meaning half of the episodes for any given condition involved only one PCP).  Episodes related to AMI involved a median of two PCPs, and episodes related to breast cancer and low back pain involved a median of zero PCPs. 34   For episode
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3. The care trajectory and care patterns differ

Exploring Episode-Based Approaches for Medicare Performance Measurement, Accountability and Payment Final Report. 3. The care trajectory and care patterns differ within and across episode types.

Our analyses examined the number of settings and types of providers that were involved in episodes related to the nine study conditions.

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