1. 1 Selected Episode Grouping Issues Frederick Thomas, Ph.D. Centers for Medicare & Medicaid Services

2. 2 Medical Episode Grouper (MEG) Etiology Based Etiology Based Disease Staging Framework Disease Staging Framework Initially developed in 1983 Initially developed in 1983 Ongoing private development by Thomson /Jefferson Medical School Ongoing private development by Thomson /Jefferson Medical School 575 categories plus stages within each category 575 categories plus stages within each category

3. 3 MEG Grouping Structure (v 7.25)

4. 4 Episode Treatment Groups (ETG) Base Category ETGs (n=330) Base Category ETGs (n=330) Resource consumption basis, with clinical homogeneity Resource consumption basis, with clinical homogeneity ETG grouping structure allows for presence of surgery, presence of comorbidities, body areas ETG grouping structure allows for presence of surgery, presence of comorbidities, body areas

5. 5 ETG 9 Digit Coding Structure (v 7.0) Base ETG: 4 digitsBase ETG: 4 digits EXPANSION ATTRIBUTES:EXPANSION ATTRIBUTES: Body location: 5 th, 6 th digitsBody location: 5 th, 6 th digits Complications indicator: 7 thComplications indicator: 7 th Co-morbidity indicator: 8 thCo-morbidity indicator: 8 th Surgery indicator: 9 thSurgery indicator: 9 th

6. 6 Example v 7. Coding

7. 7 Severity Adjustment Used to help identify complexity and resource use

8. 8 MEG Severity MEG: disease stage from 2 nd Dx (3 severity levels generally for each MEG) MEG: disease stage from 2 nd Dx (3 severity levels generally for each MEG) Examples of Dx that define stages: respiratory failure, shock (along with base condition) Examples of Dx that define stages: respiratory failure, shock (along with base condition) Conditions such as diabetes, ESRD not in stages Conditions such as diabetes, ESRD not in stages User determines severity modelUser determines severity model Disease Staging levels along with other information used to adjust costsDisease Staging levels along with other information used to adjust costs

9. 9 Disease Staging Classification Scale: likelihood of mortality Base Category MEGs(n=575) Stage 1 Disease with no complications Stage 2 Disease has local complications Stage 3 Multiple site involvement; systemic complications Stage 4 Death

10. 10 Disease Staging Example

11. 11 ETG Severity In ETG v 7.0, up to 4 levels are identified in about 125 ETGs In ETG v 7.0, up to 4 levels are identified in about 125 ETGs Severity models use Dx, age, gender to create severity profiles Severity models use Dx, age, gender to create severity profiles This model is used to assign a severity level to each ETG episode This model is used to assign a severity level to each ETG episode

12. 12 ETG Severity Score

13. 13 ETG Severity Threshold Example

14. 14 Comparsion: CHF Adjusted Costs

15. 15 Comparing Grouper Logic

16. 16 Some ETG / MEG groups have almost identical Dx Example: CHF

17. 17 Some use same DX codes, but split into different groups Example: Diabetes

18. 18 Most Dx are different

19. 19 Examples of other Logic Differences Specificity Logic (MEGs): Non-specific Dx MEGs are grouped with specific Dx MEGsSpecificity Logic (MEGs): Non-specific Dx MEGs are grouped with specific Dx MEGs Incidental logic (ETG): some Dx cannot open episodes when another is already openIncidental logic (ETG): some Dx cannot open episodes when another is already open Ranking logic (ETG): to evaluate some claim combinationsRanking logic (ETG): to evaluate some claim combinations

20. 20 Types of Episodes Chronic: conditions such as COPD, CHFChronic: conditions such as COPD, CHF Usually a calendar year (12 months duration)Usually a calendar year (12 months duration) Acute: conditions such as fracture, AMI, pneumoniaAcute: conditions such as fracture, AMI, pneumonia Episode ends when no more activity for that condition is found, i.e, a “clean period”Episode ends when no more activity for that condition is found, i.e, a “clean period”

21. 21 Resulting Cost Differences

22. 22 Philosophical Issue Example Bundling physician claims with an inpatient stay

23. 23 Inconsistency of Dx on Physician and Inpatient Facility Claims The hospital stay (facility claim) is usually grouped by the principal Dx, even though multiple conditions may be involvedThe hospital stay (facility claim) is usually grouped by the principal Dx, even though multiple conditions may be involved About 55% of physician claims Dx differ from the Dx on the inpatient claimAbout 55% of physician claims Dx differ from the Dx on the inpatient claim

24. 24 Episode with IP Stay: MEG 525 Neoplasm, Malignant Other Respiratory System

25. 25 Philosophical Question: Group all inpatient physician claims with the principal inpatient stay Dx, regardless of physician Dx? OrGroup all inpatient physician claims with the principal inpatient stay Dx, regardless of physician Dx? Or Group each physician claim by its Dx into multiple episodes, that may not include the inpatient stay?Group each physician claim by its Dx into multiple episodes, that may not include the inpatient stay?