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Episode-Based Cost and Resource Use Measurement Mark Rattray MD What are episodes of care? “A series of clinically related health care claims over a defined time period, such as all claims related to a patients diabetes” (Hornbrook et al, 1985) Middle ground between per-unit analysis and percapita analyses Provide fuller picture of care than analyzing individual services More ‘actionable’ than per-capita analyses in identifying specific drivers of resource use 2 Why episodes of care? A more logical view of care delivery Patient and condition-centric Recognizes that care is delivered over time Encompasses all care delivered for condition Potentially allows evaluation of multiple care attributes Historic focus has been on cost and resource use Can be expanded to address quality and outcomes 3 Episode groupers Commercially available Episode Treatment Groups (ETGs) – Ingenix Medical Episode Grouper (MEGs) – Thomson-Reuters Cave Consulting Planned or in development ABMS / Brookings – Approximately 20 common conditions Testing ongoing CMS – Pursuing Medicare episode of care grouper Independent, unique efforts Tailored to available data Example: Puget Sound Health Alliance 4 Episode example – Episode Treatment Groups SPECIALTY: Family Practice RESPONSIBLE CLINICIAN ID: 000003402 EPISODE TREATMENT GROUP DESCRIPTION Benign hypertension, w/o comorbidity Cardiovascular disease signs & symptoms Minor conduction disorder Allergic rhinitis Gastroenterology disease signs & symptoms Oth minor ortho disorder - neck and back Minor orthopedic trauma - neck and back Acute sinusitis Irritable bowel syndrome Oth minor ortho disorder - foot and ankle Orthopedic signs and symptoms - unspecified "" "" Minor inflammation of skin & subcutaneous tissue Benign neoplasm of the breast, w/o surgery Minor infectious disease Contraceptive management, with surgery Viral skin infection Routine exam Benign neoplasm of the skin MANAGEMENT $3,854 $1,258 $549 $760 $686 $1,450 $329 $8 $332 $210 $244 "" "" $315 ($103) ($43) ($57) $359 $513 $447 $15,588 SURGERY $3 $6 $4 $8 $599 $101 $23 $2 $88 $62 $30 "" "" ($1,337) ($97) $22 ($605) ($1,827) ($235) ($2,606) ($8,428) ANCILLARY PHARMACY $1,849 $4,180 $934 $172 $528 ($232) $659 $2 $530 $361 $181 "" "" ($970) ($384) $64 ($316) ($253) ($2,271) ($602) $3,306 $4,029 ($120) $149 $1,183 ($21) $402 ($126) $828 ($150) $112 $172 "" "" $1,475 $22 ($772) $8 $149 ($58) $7,886 FACILITY TOTAL $488 $214 $614 $171 $23 $35 "" "" $134 $2,416 $10,223 $5,539 $2,251 $2,124 $1,964 $1,720 $885 $840 $823 $780 $627 "" "" ($517) ($562) ($594) ($970) ($1,572) ($1,993) ($2,818) $20,768 5 Example community effort – Puget Sound Health Alliance Possessed claims data repository Created an episode of care – hospitalization for specific procedures – including all services during hospitalization Used 3M APDRGs categories and severity adjustment Converted claims to resource use using Milliman RVUs for Hospitals tool and physician RVUs Depicted variations in resource use for common procedures by hospital systems Started with blinded results; plan to update data and unblind next year See “Use of Resources in High-Volume Hospitalizations”: http://www.pugetsoundhealthalliance.org/documents/puget_sound_health_alliance_resource_use_report_2011.pdf 6 Episode example – Puget Sound hospitalizations for back surgery See “Use of Resources in High-Volume Hospitalizations”: http://www.pugetsoundhealthalliance.org/documents/puget_sound_health_alliance_resource_use_report_2011.pdf 7 Challenges with episodes of care Usually based on claims data; driven by coding May involve substantial investment required to create, test, and validate the coding algorithms defining an episode Defining a homogenous condition – where variation in results represents variation in resource use decisionmaking, not differences in the condition, disease severity, or patient comorbidities Do not address appropriateness of care Historically have been proprietary, not subjected to consensus evaluation as NQF has performed for quality measures 8 Thank you! Mark Rattray MD [email protected]
