Episodes

You are currently browsing articles tagged Episodes.

Quality of Care Measures Across Settings

November 15, 2010 in Medicare, Quality | No comments

How well does Medicare measure quality?  Not very well, especially across different treatment settings.  According to a RAND report:

“Only 10 clinical conditions are addressed by reporting programs for more than one setting. Three clinical conditions are included in programs for three settings: (1) acute myocardial infarction, (2) perioperative/surgical care, and (3) urinary incontinence. Seven conditions are included in programs for two settings: (1) back pain, (2) community acquired pneumonia, (3) depression, (4) end stage renal disease, (5) heart failure, (6) pain, and (7) prevention.”

By not tracking quality measures across providers or treatment settings, physician have less of an incentive to maintain quality across the patient’s full continuum of care.

Tags: , , ,

Implementing a value-based purchasing program for Medicare

January 27, 2010 in Medicaid/Medicare, P4P | No comments

“The Medicare Improvements for Patients and Providers Act of 2008 (MIPPA) requires the Department of Health and Human Services (DHHS) to develop a plan that will transition Medicare payments into a VBP [value based purchasing] program for physician and other professional services that is based on efficiency and the quality of services provided. The Act also requires the DHHS to disseminate informational reports to physicians using episode groupers and/or per capita measures.”

One way to implement VBP is to evaluate physicians based on episodes of care.  Episodes of care aggregate claims information to construct episodes.  These episodes are supposed to represent a homogeneous unit of care for a given type of treatment or disease.  A paper by Thomas et al. (2009) however, has found some problems with how episodes are constructed.  For example:

  • Many physicians typically treat a patient during an inpatient stay.  Can inpatient episodes reliably be attributed to a single physician?
  • Most Medicare inpatient stays treat multiple diseases simultaneously.  How does grouping account for these comorbitities?
  • Episode grouping is based on claim diagnosis codes.  “Since Medicare’s payment for a physician service is based on the CPT code (reflects procedure or type of visit) rather than on the diagnosis, physician offices have no incentive to spend much effort in coding a diagnosis. In contrast, the payments hospitals receive are determined by a combination of diagnosis and procedure codes.”
  • Complications from surgical care can be the fault of the doctor or from factors outside their control.   Determining whether or not the physician is at fault is extremely difficult and any physician rating system will likely blend the two causes.

Slides and a “backgrounder” from a CMS listening session on “Defining an Episode Logic” are also available.

Tags: , , , ,

How has episode-based P4P worked in California?

November 30, 2009 in Health Insurance, Managed Care, P4P, Quality | No comments

Episodes of care are defined as the bundle of medical treatments used to treat an illness over  a specified time period.  Because all treatments are bundled together, these episodes have been thought to provide a superior unit of analysis in pay-for-performance (P4P) systems.  In fact, Oxford Health Plan pioneered episode payment in the 1990s.  [Later, the health plan abandoned episode payment due to data and computer system difficulties]

How has episode-based pay-for-performance worked in California?  A paper by Robinson, Williams and Yanagihara (2009) looks at Integrated Healthcare Association (IHA) initiative.  This association of health plans, hospital systems, and medical groups manages California’s P4P program.  The P4P program gives large physician groups a P4P score based on all of its commercial HMO patients. Using the Thomson Reuters Medical Episode Grouper (MEG), $264 million was spent on the California P4P between 2003 and 2007.  Although this is the largest P4P program in the nation, it amounts to less than 2% of California physician’s income.

Using medical groups rather than individual physicians has a number of advantages.  First, a larger number of patients are attributed at the medical group level compared to the individual provider.  Also, having multiple physicians within a single group treating a patient does not complicate the analysis.  Despite the use of medical groups rather than physicians, Robinson and co-authors found a number of problems with episode-based P4P:

  • Small Sample Size: The IHA technical committee stated that a physician organization must have a minimum of 30 episodes to be evaluated.  However, most physician organizations did not have enough episodes to be scored.  The main problem is that most enrollees are healthy during the year and thus do not generate as many episodes.  However, this may be less of a problem if P4P was to be applied to Medicare beneficiaries.
  • Data Completeness: “Prior to P4P, there was little incentive for the medical group to fully code what is done to the patient (procedures) and why it is done (diagnoses) on encounter forms.”  If P4P were applied to the Medicare population, procedure codes would likely be coded more accurately (because physicians are mostly paid by the procedure), but the diagnoses fields would likely suffer from similar problems.

Today in 2009, IHA has mostly abandoned episode-based P4P.  The metrics to be used going forward include: the percentage of prescriptions filled which are generic, the percentage of ambulatory surgery procedures that take place in freestanding centers compared to hospitals, ER visits per 1000 enrollees, non-maternity hospital visits per 1000 enrollees.

The authors note that episodes of care still may be appropriate for high-volume, high cost procedures in orthopedics and interventional cardiology, but California’s enthusiasms for episode-based P4P seems to be waning.

Tags: , , , , ,