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Among the episodes that were related to the nine study conditions, there was substantial variation in average standardized payments, [33] both across episode types and among different episodes of the same type. Per episode average payments for ETGs related to the nine study conditions ranged from an average of $1,306 (episodes related to diabete

The Medicare beneficiaries for the nine conditions we examined had an average of 10 episodes during the year, and the majority of episodes were unrelated to the condition that was used as a criterion for inclusion of the beneficiary in this study.  Most episodes were of varying types (i.e. not repeated occurrence of the same type of episode). �

This study identifies a number of important issues that need to be examined in more depth, should Medicare decide to pursue any of the possible paths towards using episodes of care as a basis for performance measurement, accountability, or payment.  We highlight seven important findings and consider their implications with respect to constructin

Current Medicare performance measurement and payment policies are structured in ways that foster setting-based, provider-centric care delivery, as their design emphasizes measurement of and payment for individual services delivered by individual providers in separate settings of care. These design features foster and reinforce a silo-based approac

In this chapter, we presented the results of exploratory analyses to identify issues related to constructing and using episodes of care the purposes of measurement and aligning incentives to deliver high quality care. The episodes of care were constructed for convenience using by two commercial episode groupers, Symmetry ETGs and Thomson MEGs.

There is a wide array of attribution rules that can be used to assign episodes to providers of care. The rules can vary in terms of whether a single provider is assigned responsibility versus multiple providers being assigned responsibility. The particular types of services and the threshold used to allocate responsibility can also vary. The rules

Figures 9 and 10 show, on a per capita basis, how much of the care received by beneficiaries diagnosed with each of the nine conditions is for ETG episodes related to the condition. Figure 9. Portion of Episodes Related to Condition, ETG

The analyses presented in this section examine the extent to which there is variation in the average total payments per episode across the nine conditions and within episodes related to each of the nine conditions. These average payments have been standardized based on 2005 payment rates and payment policy to exclude variations in resource use due

As stated in the overview of our analyses, we sought to focus on conditions that are common among Medicare beneficiaries. Table 9 presents the number and percent of continuously enrolled Medicare FFS beneficiaries identified as having each of the conditions of focus using both primary and secondary diagnoses that appeared in the 2005 claims data.

To provide a sense of scale, Table 7 provides summary statistics on the number of Medicare beneficiaries residing in each of the three states in 2005 who were continuously enrolled in Medicare FFS, 2004-2006, the number of Medicare claims in 2005 for these beneficiaries and the total Medicare payments for these claims.  

We begin our presentation by examining the results generated by ETGs and MEGs to provide a reader with a sense of their comparability.  For the remainder of the chapter, our discussion focuses on the results generated by ETGs, as the MEGs results were not substantively different. The full set of results for both ETGs and MEGs are presented in th

Basic descriptive analyses for each state and episode grouper provide a broad overview of the number of episodes comprised by care delivered to Medicare beneficiaries who reside in the three states.

Many of our analyses focused on individuals diagnosed with one or more of a subset of nine clinical conditions in order to better understand similarities and differences between different types of episodes for different types of patients. We sought a mix of acute and chronic conditions that make up a large portion of Medicare cases (i.e., volume)

Figure 1 provides a high-level illustration of the approach used in our analyses.  The study population for this work consisted of Medicare FFS beneficiaries who were continuously enrolled in FFS Medicare Part A and Part B for 2004-2006, whose reason for eligibility was their age, and whose primary residence in 2005 was in one of three states: F

This chapter summarizes our approach and findings from conducting quantitative analyses of episodes of care data generated from two commercially available episode grouper tools (i.e., Symmetry ETGs and Thomson MEGs).  These analyses were intended to explore issues related to the construction and use of episodes of care for the purposes of perfor

Our review of the literature on approaches to episode-based payment and performance measurement found that a wide variety of approaches have been proposed, in some cases with a long history.  However, relatively few of the proposed approaches have been implemented and remain largely conceptual in nature.  Several approaches have been tested in

Most of the experts believed that risk adjustment is very important to episode-based approaches.  They pointed to risk adjustment as necessary in order to prevent risk selection by providers and/or insurers.  One expert stated that even disregarding other benefits, risk adjustment was necessary to get provider buy-in to episode-based approache