Medicare

Risk Adjustment of Episodes of Care for Payment

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

Most proposals in the literature acknowledge the need to risk-adjust (i.e., adojust for differences in patient populations across providers) episodes of cre for payment and some en a provider represents only a small fraction of all the care delivered and/or does not view her/himtypes of performance measurement, particularly for outcome measures.

Attributing Episodes of Care to Providers

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

A critical issue when measuring clinical performance and resource utilization is assigning responsibility (also called “attribution”) for the services or set of services that are or are not provided to a beneficiary. The building block approach, which illustrates that an episode can be constructed and used in various ways, implies different

Types of Episode Constructions that Have Been

Exploring Episode-Based Approaches for Medicare Performance Measurement, Accountability and Payment Final Report. Types of Episode Constructions that Have Been Proposed for Use

(1) Services Related to a Hospitalization. Several proposals in the literature have focused on constructing episodes of care related to a hospitalization. In many approaches in the literature, the episode would include related care provided during a post-discharge time period, potentially including post-acute institutional, home health care,

Exploring Episode-Based Approaches for Medicare Performance Measurement, Accountability and Payment Final Report. Types of Episode Constructions that Have Been Used

(1) Services Related to a Major Inpatient Procedure . This type of episode typically bundles together the inpatient and physician services payments related to a major procedure. We found four examples cited in the literature of the use of this type of episode construction for payment and in some cases for quality measurement for coronary artery

Types of Episode of Care Definitions that Have

Exploring Episode-Based Approaches for Medicare Performance Measurement, Accountability and Payment Final Report. Types of Episode of Care Definitions that Have Been Proposed or Are in Use

A broad variety of episode definitions have been used in practice or proposed in the health policy literature. Episodes of care could be constructed in a variety of ways which could encompass different parts of the continuum of care. Conceptually, health care services could be aggregated into episodes along two dimensions: aggregating relat

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

Episodes of care have been used and proposed as a unit of payment for over 25 years; however, such applications have focused on narrow definitions of what constitutes an episode of care and have not considered definitions that more broadly encompass a larger piece of or the entirety of the patient’s care trajectory. Where episode-based payment

Episodes of Care for Performance Measurement

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

The use of episodes of care for quality measurement and accountability is mostly non-existent in practice, although it has been proposed and discussed in the literature as a strategy for reforming Medicare. There are a few cases where providers are being held accountable for what percentage of their patients with a particular condition received

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

Proposed Uses and Current Applications of

Exploring Episode-Based Approaches for Medicare Performance Measurement, Accountability and Payment Final Report. Proposed Uses and Current Applications of Episodes of Care

We reviewed the empirical literature and held discussions with a small number of experts to identify what types of episodes of care or other groupings of related services have been used, tested, or proposed as a basis for performance measurement and accountability and/or payment. This review was used to inform our consideration and discussion of

Medicare Measurement Efforts do not Address the

Exploring Episode-Based Approaches for Medicare Performance Measurement, Accountability and Payment Final Report. Medicare Measurement Efforts do not Address the Continuum of Care Delivered across an Entire Episode

Current health care quality measurement efforts focus on assessing care for individual indicators of performance for a patient with a specific clinical condition or set of risk factors at discrete points in time (e.g., percentage of patients with diabetes who received an HbA1c screening test or the percentage of women between the ages of 40-69 who

Medicare Collects Quality Performance Data across

Exploring Episode-Based Approaches for Medicare Performance Measurement, Accountability and Payment Final Report. Medicare Collects Quality Performance Data across Many Settings and Conditions

For the FFS program, Medicare currently collects data on quality measures for six different health care settings:

Performance Measures Currently Reported to

Exploring Episode-Based Approaches for Medicare Performance Measurement, Accountability and Payment Final Report. Performance Measures Currently Reported to Medicare

We catalogued performance measures that are being reported to Medicare as of 2008, finding that Medicare is collecting a significant number of performance measures; however these efforts currently are single setting and provider focused and they emphasizes assessment of the provision of discrete services rather than the full spectrum of services w

Where Differential Payment Policies Exist, the

Exploring Episode-Based Approaches for Medicare Performance Measurement, Accountability and Payment Final Report. Where Differential Payment Policies Exist, the Focus is on Reporting of Performance

Differential payments to providers currently reflect additional payments for reporting rather than actual performance. As of July 2008, Medicare had pay-for-reporting programs in place for the hospital inpatient, hospital outpatient, and home health settings; these programs require providers to voluntarily report on a defined set of performance

Separate Payment Mechanisms Do not Foster

Exploring Episode-Based Approaches for Medicare Performance Measurement, Accountability and Payment Final Report. Separate Payment Mechanisms Do not Foster Coordination and Shared Accountabilities

Medicare uses separate payment mechanisms for each of its FFS provider settings and Medicare Advantage plans, and these payments are currently not aligned in ways that foster coordination, shared accountabilities, and delivery of high quality care.

Existing Medicare Provider Payment Approaches

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

We catalogued the provider payment approaches used by Medicare as of 2008, which revealed two important issues of relevance to this project.

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

Substantial deficits in the quality of health care and persistent and unsustainable growth in health care spending have led to calls for reform of the Medicare system, including such

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

Cheryl l. Damberg, Melony E. Sorbero, Peter S. Hussey, Susan Lovejoy, hangsheng liu, and ateev mehrotra WR-633-ASPE February 2009 Assistant Secretary for Planning and Evaluation U.S. Department of Health and Human Services The report was prepared by the contractor (RAND). The findings and conclusions are those of the authors and do not n

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Continuation of Research on Consumer Directed Health Plans: HSA Simulation Model Refinement . Footnotes

1 2006 Blue Book, United States Department of the Treasury, February, 2006. 2 HDHP stands for High Deductible Health Plan. This plan design generally has a substantial deductible and/or coinsurance requirement that must be met before catastrophic health insurance is activated for medical care reimbursement.

Continuation of Research on Consumer Directed Health Plans: HSA Simulation Model Refinement . Appendix A8 – Low Option PPO Health Care Expenditure Model (SAS Output)

Source DF Sum of Squares Mean Square F Value Pr > F The REG Procedure Model: MODEL1 Dependent Variable: Total_Allowed_Amount Weight: Plan_Distribution_Weight Analysis of Variance

Continuation of Research on Consumer Directed Health Plans: HSA Simulation Model Refinement . Appendix A7 – Medium Option PPO Health Care Expenditure Model (SAS Output)