Application of Episode Groupers to Medicare

Since 2006, CMS has been investigating techniques that can help identify higher cost practice patterns. One technique is to compare resource use at the episode of care level. Episodes of care represent a group of healthcare services (claims) for a health condition (e.g., hip fracture, diabetes) over a defined length of time for which a physician can be responsible. Episode groupers are software programs that organize claims data into a set of clinically coherent episodes, usually linked by diagnosis. Episode grouping software requires users to specify the input parameters for a given set of outputs. Acumen adapted Medicare claims (Parts A and B, and no Part D) for grouping, developed a framework to compare episodes generated by each grouper on a common set of claims data, and assessed the impact of the numerous grouping options and profile settings available in each grouper. Using a 20% sample of 2003 Colorado data, Acumen grouped about 5 million Medicare claims using the January 2008 versions of Symmetry Episode Treatment Groups (ETG) and the Thomson Medstat Medical Episode Grouper (MEG) software. Approximately 660,000 episodes resulted from this grouping process using either grouper software.