A descriptive analysis of Medicare hospital episodes with critical care billings : implications for bundling services for pricing

98 Pages·1993·3.6 MB·English

by  Garrison, Louis P

The
Project
HOPE
CENTER ADESCRIPTIVEANALYSISOF
for MEDICAREHOSPITALEPISODES
HEALTH
AFFAIRS WITHCRITICALCAREBILUNGS:
IMPUCAT10NSFORBUNDUNGSERVICES
FORPRICING
FinalReport
July30.1993
ProjectHOPECenterforHealthAffairs
7500OldGeorgetownRoad,Suite600
Bethesda.Maryland20814
7500OldGeorgetownRoad,Suite600,Bethesda,Maryland 20814-6133
ADESCRIPTIVEANALYSISOF
MEDICAREHOSPITALEPISODES
WITHCRITICALCAREBILUNGS:
IMPUCATIONSFORBUNDUNGSERVICES
FORPRICING
FinalReport
July30,1993
ProjectHOPECenterforHealthAffairs
7500OldGeorgetownRoad,Suite600
Bethesda,Maryland20814
"^r
TableofContents
Section Page
ListofRguresandTables iv
Preface vi
Abstract vii
Summary
viii
Section 1. Introduction 1
Section2. Background 3
2.1 DefinitionofCriticalCareServices 3
2.2 PhysicianBillingsforCriticalCareServices 5
Section3. DataFileConstmctionandMethods 7
3.1 OverviewofApproach 8
3.2 ConstructionofCriticalCareEpisodes 9
Section4. Results: HospitalStayEpisodeswithCriticalCareBillingsand
ICU/CCUUse 16
4.1 Demographics 16
4.2 CodingandFrequencyofCriticalCareUse 16
4.3 CostsandChargesAssociatedwithCriticalCareUse 19
4.4 AnalysisofVariations 22
4.5 UseofRelatedandLocalHCPCCodes 31
Section5. Discussion 35
5.1 SummaryofKeyRndings 35
5.2 VariationsinCodingandBilling 36
55..34 TImhpeliNcaetwionCrsitfiocralBuCnadrleinCgoadnedsAlternativePaymentSchemes .. 3407
Section6. Conclusion 43
References 45
u
TableofContents(continued)
Appendices:
A. TKaeblyeMAe-a1s:uMreesanbsyaDnRdGCoefficientsofVariationsfor A-1
B. ListofHCPCCodesUsedMoreThan500timesin
53,091 CriticalCareHospitalStayEpisodes B-1
C. ListofCarrierLocalCodesforProcedures
RelatedtoCriticalCare C-1
lU
ListofFiguresandTables
Figures Page
Figure1: CriticalCarePhysicianBillingCodes 4
Figure2: InitialRieConstructionSteps 11
Tables
Table1: UseofCriticalCarePhysicianServices, 1987 6
Table2: FrequencyDistributions: DemographicVariables 17
Table3: CodingofCriticalCareEpisodes: FrequencyofCodeUse ..18
Table4: CombinationsofCriticalCareCodesUsedin
AtLeastOnePercentofCases 20
Table5: AllowedChargesforCriticalCareServices 21
Table6: FrequencyDistributions: TotalAllowedChargesfor
AllBilledCriticalCareServices 23
Table7: ComparisonsofKeyVariables: MeansandCoefficients
ofVariation 24
Table8: Diagnosis-RelatedGroupsUsed
inMoreThanOnePercentofCases) 26
Table9: AComparisonofCriticalCareCodesBilled,
TotalAllowedCharges,andICU/CCUDaysByDRG 27
Table10: AComparisonofCriticalCareAllowedCharges,Total
HospitalCharges,andtheRatioofCriticalCareCharges
toTotalHospitalChargebyDRG 28
Table11:SAerCvoimcepsarainsdonAllofOtBihlelringPsarftorBCrSietricvailceCsarbeyPDhRysGician 29
Table12: HCPCCodesUsedOver7,000TimesDuring
CriticalCareEpisodes 32
IV
ListofFiguresandTables(continued)
TableA-1: MeansandCoefficientsofVariationforKeyMeasures
byDRG A-1
Prefece
Likemanydata-intensiveresearchprojectsusingverylargedatafiles,thisone
beganwithoverlyambitiousaimsthatweregraduallymodifiedastheprojectevolved.
Thedifficultiesinvolvedinmanipulatingtheselargefilesplayedalargeroleinthe
eventualdevelopmentandexecutionoftheproject. LouGarrisonservedasthe
projectleader. VeraKuriantzickandBethMcLaughlinweretheotherkeyanalystson
theproject. YiminNganofSocialandScientificSystems,Inc.,didthebulkofthe
analyticprogramming. PortiaDeFilippesofProjectHOPEwasresponsibleforthe
initialcomputationsattheHCFADataCenter. SheldonRetchinofProjectHOPE
servedasaconsultantreviewerandmademanyusefulsuggestionseariyoninthe
project.
StaffoftheHCFAOfficeofResearchandDemonstrationsweresupportiveand
patientthroughouttheproject. Themembersoftheprojectteamremaingratefulfor
tthheeedfaftoartpsroofbloeumrsi.nitiWaleHwCoFulAdparoljseoctlikoefftiocert,haRnokbeorutrGsruubbseerq,uteontaspsriosjtecutsoifnfiocveerrsc-oming
MichaelBorowitzandWilliamBuczko-fortheirassistance. Thisfinalreportbenefitted
fromthecommentsofanonymousHCFAreviewersonaneariierdraft. Thisreport
describestheworkcompletedunderthisprojectandshouldbeofassistancetoORD
andfutureresearchersinterestedintheprovisionofcriticalcareservices.
VI
Summaiy
Thepurposeofthisprojectwas(1)toanalyzebillingandutilizationpatternsfor
physiciancriticalcareservicesprovidedtoMedicarebeneficiairesand(2)toassess
theimplicationsofthesefindingsforbundlingtheseservicesforpricing. Thestudy
usedthe1987PartA/PartBMergedFile,representingafivepercentsampleofall
beneficiaries. Extensivecomputationswererequiredtoisolateandconstructhospital
stay"episodesofcare"involvingcriticalcareuse. Billingsrelatedtothesixprincipal
criticalcarecodeswerelinkedtospecifichospitalstaysthatincludedreporteddaysin
intensiveorcoronarycareunits. Theprincipalanalyticfileconsistedofsome53,000
hospitalstayepisodesinvolvingbothICU/CCUuse(aPartAbilling)andcriticalcare
billings(PartB).
Asubstantialvolumeofhospitalizations(over74,000discharges)involving
criticalcare,asIndicatedbyreportedICU/CCUdays,didnothavereporteduseofany
ofthesixcriticalcarevisitcodes. Itisimportanttonotethattheseepisodeswerenot
studiedindetail. Thedetailedanalysesfocusedonthe53,000hospitalstayepisodes
withbothICU/CCUuseandcriticalcarePartBbillings,andyieldedseveralkey
findings:
1) Evenamongthosedischargesindicatingsomecriticalcarephysician
use,therewasconsiderablevariabilityinbillingpattemsintermsofthe
typesandfrequencyofcodesused.
2) Totalbillingsforfollow-upcriticalcarevisitcodesweremuchhigherthan
thosefortheinitialvisitcodes: theyaccountedforabout73percentof
totalcriticalcarephysicianspending.
3) Comparedtototalhospitalchargesandotherphysicianchargesper
episode,averagecriticalcarephysiciancharges($270.80perepisode)
weresmallonaverage-about2percentoftheformerand12percentof
thelatter.
4) AmongdischargeshavingbothICU/CCUuseandcriticalcarebillings,
perhospitalstayspendingoncriticalcarephysicianservices(mean
coefficientofvariation(CV)=167percent)variedmoreonaveragethan
viii
thatforeitherhospitalcharges(meanCV=150percent)orother
physiciancharges(meanCV=124percent).
5) Amongthesehospitalepisodeswithcriticalcarephysicianbillings,on
average,fewerthanonecriticalcareservice(0.55onaverage)wasbilled
perdayintheICU/CCU.
6) Forthisanalyticsample,episodesfallingintoonly25DRGsaccounted
for70.3percentofallhospitalepisodeswithcriticalcarephysician
servicebillings.
7) Amongthese25DRGs,averagewithin-DRGvariabilityforcriticalcare
physicianbillings(meanCV=127percent)wasgreaterthanthatfortotal
hospitalcharges(meanCV=103percent)orfortotalotherphysician
charges(meanCV=91 percent).
8) Acrossthese25DRGs,thevariabilityintheaveragecriticalcarebilling
(CVacrossthemeans=34percent)waslowerthanfortotalhospital
charges(CVofmeans=71 percent)andforotherPartBbilledservices
(CVofmeans=106percent).
9) CriticalcarebillingsperICU/CCUdayvariedlittle(CVofmeans=10
percent)acrossthese25DRGs;theaveragenumberofICU/CCUdays
variedmore(CVofmeans=38percent).
10) Within-DRG,forthese25DRGs,theaveragevariabilityinICU/CCUdays
wasmoderate(meanCV=110percent),comparedtothe127percentfor
criticalcarechargesandthe103percentfortotalhospitalcharges.
11) Forthecriticalcareepisodesinthese25mostfrequentlyoccurring
DRGs,boththenumberofotherphysicianbillings(21.2procedurecodes
onaverage)andthetotalbillings($1774.84)farexceededthenumber
billedcriticalcarecodes(2.83)andtherelatedbillings($262.36).
Thesefindingsindicatethatcodingpracticesandbillingsforcriticalcare
physicianservicesin 1987exhibitedsubstantialvariability. Onahospitalepisode
basis,paymentsforphysiciancriticalcareserviceswerequitesmall(andmore
variable),ascomparedtothetotalepisodecost. Thetotalphysicianbillfortheentire
episodewasamorestableandmuchlargerproportionofthetotalcost. Asa
potentialcase-mixadjuster,DRGsperformedbetterforallPartBphysicianservices
andtotalhospitalchargesthanforcriticalcareservices. Thenumberofcriticalcare
IX
codesbilledwasconsistentlyandsignificantlylessthanthenumberofICU/CCUdays
reportedforthe25DRGsinvolvingsubstantialcriticalcareuse. Allofthissuggests
that: (1)someclarificationisneededregardingthecodingofcriticalcareservicesand
(2)theremaybelimitedutilityinbundlingtheseservicesaloneonaDRG-basisorper
diembasis(intheICU).
Severalimportantlimitationsofthisanalysisshouldbehighlighted. First,it
examinedindetailonlyaportionoftheMedicarepatientsreceivingcriticalcare. In
particular,thesedischargesreflectedanarrowdefinitionofahospitalstayepisode
Involvingcriticalcareuse. Second,noadjustmentsweremadeforgeographiccostof
livingdifferences,billingpracticesofsurgeonsandresidents,orlocalcodes. Third,
thevariationsincodingandbillingpracticesintroduceerrorintothesubsequent
analysisofspendingpatterns.
RecentchangesincriticalcarecodingunderthenewMedicarefeeschedule
addressthiscodingissueaswellastheincentivetobillfollow-upcriticalcarecodes.
However,theymakeitlessfeasibleandlesslogicaltodevelopaseparateperepisode
paymentbundleforcriticalcare. Theyalsodonotmakeitanyeasiertoconduct
researchonthistopic,since(a)someproceduresarebundledinthecriticalcare
constantattendancecodesand(b)subsequenthospitalvisitcodesaretobeusedfor
routinecaretocriticalcarepatients. Globalsurgicalbillingpolicyandbillingby
residentsfurthercomplicatesthesituation. Thus,futureresearchonphysician
servicesprovidedtocriticalcarepatientsislikelytorequiredetailedchartreview.
Basicresearchonthestructureandoperationofcriticalstaffingwouldalsobean
importantcontribution, Rnally,researcheffortstosupportpoliciestocontainphysician
inpatientservicegrowthmightbetterfocusonanalysisofthepotentialforbundlingall
inpatientphysicianservicesonanepisodebasis. Thereisalsoaneedforoutcomes
researchoncriticalcaretoaddressitscosteffectiveness.