1. Episodes of Care: Background and Issues James M Naessens, ScD Division of Health Care Policy & Research Mayo Clinic

2. Outline Episodes of Care Episodes of Care Background Background Approaches Approaches Current Issues with Episodes Current Issues with Episodes CMS CMS Health Affairs Sept/Oct 2009 Health Affairs Sept/Oct 2009 Mayo Clinic Studies Mayo Clinic Studies Referral Practice Referral Practice Chronic Disease Cohorts Chronic Disease Cohorts

3. Episodes of Care Concept first introduced in 1960’s by Solon J, et al.^ Concept first introduced in 1960’s by Solon J, et al.^ Advanced by Hornbrook M, et al.* Advanced by Hornbrook M, et al.* “series of temporally contiguous health care services related to treatment of a given spell of illness or provided in response to a specific request by the patient” “series of temporally contiguous health care services related to treatment of a given spell of illness or provided in response to a specific request by the patient” * Med Care Rev. 1985;42:163-218 ^ American Journal of Public Health. 1967;57:401-408

4. Episode of Care Uses Provide measurement and treatment guidelines for physicians Provide measurement and treatment guidelines for physicians Define boundaries of reimbursement Define boundaries of reimbursement Determine risk adjustment Determine risk adjustment For health care utilization analysis For health care utilization analysis Operational aspects of health care delivery (Mayo Clinic medical record management) Operational aspects of health care delivery (Mayo Clinic medical record management)

5. Episode of Care Current Basis for Payment Projects Geisinger - Cardiac Surgery “guarantee” Geisinger - Cardiac Surgery “guarantee” Medicare Acute Care Demonstration Project – bundling for ortho and CV procedures Medicare Acute Care Demonstration Project – bundling for ortho and CV procedures Medicare Physician Hospital Collaboration demonstration – immediate post hospital period Medicare Physician Hospital Collaboration demonstration – immediate post hospital period

6. Our Problem Outpatient Care Analysis Capitated model / primary care Capitated model / primary care  Patient Fee for service model Fee for service model  Encounter  Service Referral care Referral care  Episode (??)

7. Billing Data (Input into MEG) DateDiagnosisEpisode 2Unspecified disease of the pericardium1 10-11Acute pericarditis, unspecified Tricuspid valve disorders, nonrheumatic Essential hypertension, unspecified111 14Dyspnea & oth respiratory abnormalities Dysuria Chest pain, unspecified Noninfectious gastroenteritis and colitis3232 16 2 21Dyspnea & oth respiratory abnormalities Chest pain, unspecified33 25Unspecified disease of the pericardium1

8. Example: one patient’s visits for one month Episode 1 Episode 3 Episode 2 Colored days represent days the patient was received services.

9. Episode Groupers Rosen and Mayer-Oakes* compared four major episode grouper programs: Rosen and Mayer-Oakes* compared four major episode grouper programs: Episode Treatment Groups (ETG) Episode Treatment Groups (ETG) Clinical Episode Groups (CEG) Clinical Episode Groups (CEG) Physician Review System Physician Review System CareTrend CareTrend With no distinctly superior product *Jt Comm J Qual Improv. 1999;25:111-28

10. Episode Groupers: Methodological Issues Starting Point (diagnosis, symptom or visit) Starting Point (diagnosis, symptom or visit) End Point (defined length or “clean period”) End Point (defined length or “clean period”) Comprehensiveness of Services (concurrent episodes?) Comprehensiveness of Services (concurrent episodes?) Clinical Complexity (chronic disease with flare-ups, unrelated acute illness, multiple comorbidities) Clinical Complexity (chronic disease with flare-ups, unrelated acute illness, multiple comorbidities) Provider Attribution Provider Attribution

11. CMS Episode Grouper Listening Session November 10, 2009 CMS intends on using input to write RFP on developing a transparent software for episodes of care for Medicare beneficiaries CMS intends on using input to write RFP on developing a transparent software for episodes of care for Medicare beneficiaries Multiple Chronic Conditions Multiple Chronic Conditions Post-acute Care Post-acute Care Length of Chronic Episode Length of Chronic Episode Physician Services Physician Services Risk Adjustment Risk Adjustment

12. Health Affairs Sept/Oct 2009 issue Episode-Based Performance Measurement And Payment: Making It A Reality Peter S. Hussey et al. Episode-Based Performance Measurement And Payment: Making It A Reality Peter S. Hussey et al. From Volume To Value: Better Ways To Pay For Health Care Harold D. Miller From Volume To Value: Better Ways To Pay For Health Care Harold D. Miller Measurement Of And Reward For Efficiency In California’s Pay-For- Performance Program James C. Robinson et al. Measurement Of And Reward For Efficiency In California’s Pay-For- Performance Program James C. Robinson et al.

13. Hussey article Applies ETGs and MEGs to Medicare part A & B data for 3 states, 2004-6. Identifies Issues with: Identifies Issues with: Defining Episodes Defining Episodes Different settings Different settings Single- vs. multi-condition focus Single- vs. multi-condition focus Within group heterogeneity Within group heterogeneity Attributing responsibility Attributing responsibility Calls for more empirical work Calls for more empirical work

14. Miller article Suggests that each of 4 methods: FFS, Episodes, Capitation, Comprehensive care payments (condition-adjusted capitation) has role Issues to address: Bundling challenges Bundling challenges Setting payment amounts Setting payment amounts Assuring quality Assuring quality Aligning incentives Aligning incentives

15. Robinson article Reviews the California Integrated Healthcare Association Pay for Performance experience addressing efficiency using episodes (MEG) Issues: Small numbers of patients/episode Incomplete data Weights (standard or actual costs)

16. Mayo Cardiovascular Referral Practice Study Goals Do Medstat’s Episodes provide a useful management tool to help understand a multi-specialty group practice? Do Medstat’s Episodes provide a useful management tool to help understand a multi-specialty group practice? Can we use MEG as a basis to understand different use patterns between rural and urban patients? Can we use MEG as a basis to understand different use patterns between rural and urban patients?

17. Methods Patients All patients seen in 2003 All patients seen in 2003  For outpatient service  By a cardiovascular provider  N=102,406 Setting Mayo Clinic, Rochester, MinnesotaMayo Clinic, Rochester, Minnesota

18. Comparisons of Interest Primary care vs. referral Primary care vs. referral Mayo Health System Mayo Health System Local vs. regional vs. national Local vs. regional vs. national

19. Episode Outcomes Cardiovascular intensity Cardiovascular intensity  Low Diagnostic  Cardiovascular E & M  High Diagnostic  Therapy Procedures Hospitalization Hospitalization Cost Cost

20. Statistical Methodology Outcome models Outcome models  Do the types of episodes differ?  Are the outcomes (average cost, hospitalization, and cardiovascular intensity) different between rural vs. urban patient after incorporating episode type, severity of episode and comorbidity?

21. Statistical Methodology Logistic and linear regression models developed to account for impacts of Mayo primary care, distance traveled, age, gender, pay source, and physician vs. self- referred. Logistic and linear regression models developed to account for impacts of Mayo primary care, distance traveled, age, gender, pay source, and physician vs. self- referred. Impact of rural-urban influence added to adjusted model. Impact of rural-urban influence added to adjusted model.

22. Summary Findings 96,601 patients with CV provided service in 2003 96,601 patients with CV provided service in 2003 287,162 outpatient CV visits and 29,369 hospitalizations in 464,067 episodes (90,922 CV episodes) 287,162 outpatient CV visits and 29,369 hospitalizations in 464,067 episodes (90,922 CV episodes)

23. Most Frequent Episodes with Cardiologist E & M Visit #% Angina pectoris 911611.0 Arrhythmias69938.4 Essential hypertension, chronic maint 42705.2 Preventive health services 29713.6 Other respiratory symptoms 28823.5 Complications surgical/medical care 23462.8 Cardiomyopathies22242.7 Osteoarthritis19332.3 Aortic stenosis 17492.1 Mitral stenosis 16652.0

24. Episodes with Cardiologist E & M Visit 14 conditions had 1000+ episodes 14 conditions had 1000+ episodes 22 conditions had 500 - 999 episodes 22 conditions had 500 - 999 episodes 74 conditions had 100 - 499 episodes 74 conditions had 100 - 499 episodes 62 conditions had 50 - 99 episodes 62 conditions had 50 - 99 episodes 450 conditions had episodes 450 conditions had episodes

25. Influence of Distance and Primary Care

26. Cardiovascular Intensity Episodes with CV E & M

28. Mean Charge per Episode

29. Summary Episodes in Specialty Practice Episodes of care were able to categorize both primary care and referral patients. Episodes of care were able to categorize both primary care and referral patients. However, after adjustment mean costs per episode differed significantly between the two groups for many types of episodes. However, after adjustment mean costs per episode differed significantly between the two groups for many types of episodes. Episodes developed for managed care practices may have limited utility for referral specialty practices. Episodes developed for managed care practices may have limited utility for referral specialty practices. Further assessment needed on the differences between primary care and referral practice episodes. Further assessment needed on the differences between primary care and referral practice episodes.

30. Mayo Chronic Disease Cohort Study Goal How well do various systems capture and characterize the health care costs of people with chronic disease? How well do various systems capture and characterize the health care costs of people with chronic disease?

31. Methods Patients Mayo employees/dependents with continuous health benefit enrollment from 2003-2006 Mayo employees/dependents with continuous health benefit enrollment from 2003-2006  Cohort 1: Meet HEDIS definitions for diabetes in 2000-2003  Cohort 2: Meet HEDIS definitions for CAD in 2000-2003 Data Source Medical and Pharmacy ClaimsMedical and Pharmacy Claims

32. Methods Generate Total Costs for 2003-2006 Generate Total Costs for 2003-2006 Apply Prometheus Models to Cohort Apply Prometheus Models to Cohort Apply ETGs to Cohort Apply ETGs to Cohort WORK IN PROGRESS! WORK IN PROGRESS!

33. Diabetes Cohort 96% 92% 21%

34. CAD Cohort 69% 60% 16%

35. Summary Episodes in Chronic Disease Cohorts Different schemes identify different patients in disease cohorts. Different schemes identify different patients in disease cohorts. ETGs and Prometheus capture only a portion of costs of Diabetes and CAD cohorts. ETGs and Prometheus capture only a portion of costs of Diabetes and CAD cohorts. ETG hierarchy influences what they consider as disease-related costs. ETG hierarchy influences what they consider as disease-related costs.