Medicare

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

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

Exploring Episode-Based Approaches for Medicare Performance Measurement, Accountability and Payment Final Report. 6. Conclusion

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

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

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.

Implications of Beneficiaries with High Disease

Exploring Episode-Based Approaches for Medicare Performance Measurement, Accountability and Payment Final Report. Implications of Beneficiaries with High Disease Burden

Geographic Variation and Out of State Care

Exploring Episode-Based Approaches for Medicare Performance Measurement, Accountability and Payment Final Report. Geographic Variation and Out of State Care

Exploring Episode-Based Approaches for Medicare Performance Measurement, Accountability and Payment Final Report. Attribution of Care to Providers

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

Number of Providers and Settings Involved in

Exploring Episode-Based Approaches for Medicare Performance Measurement, Accountability and Payment Final Report. Number of Providers and Settings Involved in Episodes Related to Conditions

Extent to Which Beneficiaries' Care is for

Exploring Episode-Based Approaches for Medicare Performance Measurement, Accountability and Payment Final Report. Extent to Which Beneficiaries' Care is for Episodes Related to Conditions of Focus

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

Variations in Standardized Payments for Episodes

Exploring Episode-Based Approaches for Medicare Performance Measurement, Accountability and Payment Final Report. Variations in Standardized Payments for Episodes Between and Within Conditions

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

Summary Statistics for Selected Conditions of

Exploring Episode-Based Approaches for Medicare Performance Measurement, Accountability and Payment Final Report. Summary Statistics for Selected Conditions of Focus across the Three States

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.

Summary Statistics for Continuously Enrolled

Exploring Episode-Based Approaches for Medicare Performance Measurement, Accountability and Payment Final Report. Summary Statistics for Continuously Enrolled Beneficiaries

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.

Results of Quantitative Analyses of Episodes of

Exploring Episode-Based Approaches for Medicare Performance Measurement, Accountability and Payment Final Report. Results of Quantitative Analyses of Episodes of Care

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

Exploring Episode-Based Approaches for Medicare Performance Measurement, Accountability and Payment Final Report. Overview of Analyses Conducted

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.

Exploring Episode-Based Approaches for Medicare Performance Measurement, Accountability and Payment Final Report. Nine Conditions Selected for Analysis

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)

Exploring Episode-Based Approaches for Medicare Performance Measurement, Accountability and Payment Final Report. Overview of the Analytic Sample

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

Exploring Episode-Based Approaches for Medicare Performance Measurement, Accountability and Payment Final Report. 5. Analysis of Episodes of Care

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

Summary of Findings from Literature Review and

Exploring Episode-Based Approaches for Medicare Performance Measurement, Accountability and Payment Final Report. Summary of Findings from Literature Review and Expert Discussions

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

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

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

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

We asked experts for their opinions on various approaches to attribution, including attribution to single versus multiple organizations, prospective versus retrospective attribution, and attribution to integrated versus virtual groups of providers. The area where the experts expressed the strongest opinions was on prospective versus retrospective

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

We asked experts for their views on the pros and cons of different episode definitions, with particular reference to three potential types of definitions under a building block approach (single setting, multiple types of providers in a single setting, and then across the continuum of Medicare settings). Most experts professed a strong preferenc

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